- Medical Review
- Medical Review Focus Areas
- Service Specific Post-Payment Audits of Home Health PDGM Bills
- Service Specific Post-Payment Audits for Hospice Length of Stay > 730 Days
- Service Specific Post Payment Review of Psychotherapy, 60 Minutes with Patient – CPT 90837
- Service Specific Post Payment Review of Ambulance Transport and Mileage When Billed With Modifiers RJ, JR, RG, GR, NJ, JN, NG, GN
- Service Specific Post-Payment Audits of Home Health Value Code 17 Bills
- Announcing Service Specific Post-Payment Audits of Hyperbaric Oxygen (HBO) Services for J6 A Regions: IL, WI, and MN
- Service Specific Post-Payment Medical Review Notice Home Health PDGM (Edit 5AAGP)
- Service Specific Post Payment Review of Botulinum Injection, onabotulinumtoxina, 1 Unit – CPT J0585
- Service Specific Post Payment Review of Floweramnioflo, 0.1 CC – CPT Q4177
- Service Specific Post Payment Review of Grafix Prime (CPT Q4133)
- Service Specific Post Payment Review of Nonemergency Ambulance Transport and Mileage
- Service Specific Post Payment Review - Hospice GIP Services Over 7 Days (5ANLP) for JK A Regions: NY/CT, MA, ME, NH/VT and RI
- Service Specific Post Payment Review of Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post Payment Review of Fluoroscopic Guidance for Needle Placement - CPT 77002
- Service Specific Post Payment Review of Computed Tomography, Abdomen and Pelvis with Contrast Material(s) - CPT 74177
- Service Specific Post Payment Review of Darbepoetin Alfa Injection, 1 microgram (Non-ESRD Use)
- Service Specific Post Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy With Therapeutic Exercise – CPT 97113
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days
- Service Specific Post Payment Medical Review Summary Results of Home Health Value Code 17 Bills
- Review Results For Service Specific Postpayment Review of Psychotherapy, 60 Minutes With Patient
- Service Specific Post-Payment Medical Review Notice Hospice with Length of Stay over 730 Days (Edit 5ANKP)
- Service Specific Post-Payment Audits of Hospice GIP Care, DOS 3/1/2020 and After
- Service Specific Post-Payment Audits of Home Health LUPA Claims
- Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, If Performed); First 20 Square Centimeters or Less– CPT 11042
- Service Specific Post-Payment Review of Tangential Biopsy of Skin-Single Lesion CPT 11102 with Destruction-Premalignant Lesion-First Lesion CPT 17000
- Service Specific Post Payment Review Summary Results – Home Health PDGM Bills (Edit 5AAGP)
- Review Results for Service Specific Post-Payment Review of Artacent Wound, per Square Centimeter - CPT Q4169
- Review Results for Service Specific Post-Payment Review of Q4133 - Grafix Prime
- Announcing Service Specific Post-Payment Audits of Group Psychotherapy Services for J6 A Regions: IL, WI and MN
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
- Service-Specific Postpayment Medical Review Summary Results of Home Health PDGM Bills
- Review Results for Service Specific Post-Payment Review of Hyaluronan or Derivative - CPT J7326
- Review Results for Service Specific Post Payment Review of Hyaluronan or Derivative – CPT J7327
- Review Results for Service Specific Post-Payment Review of Fluoroscopic Guidance for Needle Placement
- J6_B_Review Results for Service Specific Post-Payment Review of J0585 – Botulinum Injection, Onabotulinumtoxina
- Review Results for Service Specific Post-Payment Review of Computed Tomography, Abdomen And Pelvis; With Contrast Material(s)
- Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113
- Review Results for Service Specific Post Payment Review of Floweramnioflo
- Review Results for Service Specific Postpayment Review of Tangential Biopsy of Skin; Single Lesion CPT 11102 with Destruction, Premalignant Lesion; First Lesion CPT 17000
- Review Results for Service Specific Post-Payment Review of Darbepoetin Alfa Injection (Non-ESRD Use)
- Service Specific Post-Payment Review Summary Results – Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post-Payment Review Summary Results – Hospice GIP Services Greater than 7 Days (Edit 5ANLP)
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After
- Service Specific Post Payment Medical Review Summary Results of Home Health Low Utilization Payment Adjustment Claims
- Announcing Service Specific Post-Payment Audits of Individual Psychotherapy Services for J6 A Regions: IL, WI and MN
- Review Results for Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, if Performed); First 20 Square Centimeters or Less – CPT 11042
- Service Specific Post Payment Review of Artacent Wound, Per Square Centimeter - CPT Q4169
- Service Specific Post-Payment Audits of Hospice GIP Care
- Service Specific Post Payment Review of Hyaluronan or Derivative - HCPCS J7326, J7327
- Skilled Nursing Facility Education Center
Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113
Background
In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT code 97113 (Aquatic therapy with therapeutic exercises, 1 or more areas, each 15 minutes).The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.
NGS randomly selected 400 claims billed for CPT 97113 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.
- CPT code 97113 (Aquatic therapy with therapeutic exercises, 1 or more areas, each 15 minutes).
Results
Decision | Number of Claims |
---|---|
Allow | 157 |
Deny | 174 |
Partially Deny | 1 |
Non-Response Denial | 67 |
- 189 claims from Illinois with 74 allowed and 115 denied for a claims error rate of 60.85%
- 118 claim from Minnesota with 40 allowed and 78 denied for a claims error rate of 66.10%
- 93 claims from Wisconsin with 43 allowed and 50 denied for a claims error rate of 53.76%
Key Reasons Services Were Denied
- Documentation did not support medically necessity due to one or more of the following: records did not support the skills of a therapist were required, records did not include physician certification, initial evaluation, the plan of care, including the prior level of function, the frequency and duration of services or goals with time line for completion.
- Documentation was insufficient or incomplete
- Failure to respond to the request for documentation
Recommendations
- Send the requested records within the requested time frame to avoid a denial for no documentation
- Familiarize yourself with available Physical Therapy use guidelines and other CMS publications listed below
- Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
- If you feel your application of this code is correct, ensure your documentation supports your usage.
Related Content
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled
- Section 1815 – Payment to Providers of Services Social Security Act Section 1815
- Section 1833(e)- Payment of Benefits Social Security Act Section 1833
- Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners. Social Security Act Section 1861
- Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer and Section 1862(a)(20) Social Security Act Section 1862
- Code of Federal Regulations, Title 42 Public Health
- 42 CFR, Sections 410.59 through 410.61, 410.74, 410.75, 410.76, 419.22, 424.24, 424.27, 424.4, 482.56, 484, 485.705 and 486 Code of Federal Regulations - Title 42
- CMS Publications: Internet Only Manuals
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: Sections 220 through 230, Coverage and documentation requirements for physical and occupational therapy services.
- CMS IOM Publication 100-03, Medicare National Coverage Decisions (NCD) Manual, (multiple sections): provides coverage information on several specific types of therapy services.
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2, financial limitation for therapy services (therapy cap) and Section 20-100 HCPCS coding and therapy billing requirements.
- Local Coverage Article: Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
- Local Coverage Determination: Outpatient Physical and Occupational Therapy Services (L33631)
Posted 12/9/2021
Targeted Probe and Educate Manual
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Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.